Provider Demographics
NPI:1952513640
Name:KRYSTAL, LAURA JEAN (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:KRYSTAL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 SANTA FE CT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-1432
Mailing Address - Country:US
Mailing Address - Phone:630-306-5016
Mailing Address - Fax:
Practice Address - Street 1:55 W 22ND ST
Practice Address - Street 2:SUITE 112
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4854
Practice Address - Country:US
Practice Address - Phone:630-424-9367
Practice Address - Fax:630-424-9368
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional